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Part B Insider (Multispecialty) Coding Alert


OIG to Address Issues in Care Management, Prolonged Services, and More in 2017

The latest Work Plan focuses on several new areas of concern for the OIG.

Starting Jan. 1, you’ll want ensure that your Chronic Care Management (CCM) claims are in line because OIG has released its long-anticipated 2017 Work Plan. This upcoming year, the agency intends to target issues with anesthesia, prolonged services, and more.

What the Work Plan is: The OIG Work Plan details issues that the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General will address during the fiscal year. The agency published its latest document on Nov. 10, which outlines the target areas it will be reviewing in 2017, and we’ve got the highlights below.

Watch Your Financial Relationships

With a spotlight on the Sunshine Act (see the CMS open payments factsheet here for more detail:, OIG plans to extend its efforts to study the payment patterns of providers and the services and products they order, scrutinizing the relationship between the provider and the supplier. “We will analyze 2015 data extracted from the Open Payments website to determine the number and nature of financial interests,” the Work Plan states.

Take note. As violation of the Stark Law is high on the OIG’s radar, providers should be warned and have ready clear documentation that their financial relationships are in check and that the services, drugs, or products were both medically necessary and reasonable.

What’s Not Covered Under Care Management

Two areas of concern for Part B providers in this year’s overview relate to chronic care and transitional care management. With strict guidelines to follow, OIG suggests you remember that these services are not covered under these CPT® codes:

  • CCM falls under the CPT® code 99490 (Chronic care management...) and refers to non-face-to-face care » for Medicare beneficiaries that have multiple chronic issues. OIG reminds that “CCM cannot be billed during the same service period as transitional care management, home health care supervision/hospice care, or certain end-stage renal disease services.”
  • The CPT® code range 99495-99496 (Transitional Care Management Services…) targets Transitional Care Management (TCM) services, but OIG warns that “Medicare-covered services, including chronic care management, end-stage renal disease, and prolonged services without direct patient contact, cannot be billed during the same service period as TCM” and are therefore not covered under them.

Here Are a Few Other Quick Takeaways

Anesthesia services, outpatient physical therapy and chiropractic care. These three common services are often ordered by physicians, but keep an eye on what’s reasonable and necessary next year as the OIG has identified them as perennial points of contention for compliance.

Prolonged services. One of the OIG’s 2017 intentions is to evaluate whether prolonged services were reasonable. “The necessity of prolonged services are considered to be rare and unusual,” the OIG says in the Work Plan. Therefore, if you’re billing prolonged services (such as 99354 and 99355) for the majority of your E/M services, you’re definitely considered an outlier.

Lab tests. According to the OIG Work Plan, the top 25 lab tests across the board will be reviewed to ensure that the requirements under the Protecting Access to Medicare Act of 2014 (PAMA), which “requires CMS to replace its current system of determining payment rates for Medicare Part B clinical diagnostic laboratory tests with a new market-based system that will use rates paid to laboratories by private payers,” are being met.

For a closer look at the OIG’s 2017 Work Plan, visit OIG Work Plan 2017.pdf.